“(Blockchain) is a very nuanced space. It is a space that is brand new. It is a space that has existed for only 7 years. And yes, it does represent something truly revolutionary– a fundamental change in our understanding of trust, a change in the way we organize authority and trust from hierarchical systems to network-centric flat systems…. A new system for disintermediating intermediaries, a rebalancing of world affairs… A system that allows innovation without permission, coercion, or political manipulation…”

Computers and other electronic devices permeate our lives. The world as we know it would not be possible without the increasingly pervasive incorporation of technological advances into essentially every single facet of our daily routines. Although steady and relentless progress in this area can be traced back to the 1950's, accelerated growth began in the late 1990s and early 2000s with the so-called “internet revolution.”[2],[3],[4] As a result, previously unforeseen increases in productivity, automation, and standards of living became possible.[5],[6] Beyond obvious economic effects of this tremendous paradigm shift, the incorporation of technological advances into various aspects of our daily lives led to the transformation of our social fabric and the way we see (and interact with) the world.[7],[8],[9],[10],[11],[12]

Inherent to the widespread adoption of ever more efficient electronic devices was the systemic capacity to create a distributed database of records, a “public ledger” or sorts, where all transactions or “digital events” that have occurred are shared among participating parties.[13] A blockchain is such a functionality, where information – once entered – can never be erased, where each transaction in this “public ledger” is verified by consensus of a system-wide majority of participants.[13] It has been postulated that the blockchain technology is one of the most innovative and disruptive developments in history, effectively creating “…a public ledger of value transfer…” readily applicable to “…information, copyright, deeds, wills, almost anything you think of….”[14]

As academic physicians, it is only natural for us to ask, “How could this technology be of benefit to the academic medical community?” In this Editorial, we will present a brief overview of the blockchain technology, its current and future applications in medicine and academia, as well as the potential to revolutionize how medical care, insurance and payment systems, academic recognition, and scientific merit can all be objectivized globally through implementing existing blockchain-based solutions.

Blockchain Technology

In simplified terms, blockchain technology consists of decentralized digital information that is distributed across a network of “interconnected nodes” and continually updated.[15] Don and Alex Tapscott, authors of Blockchain Revolution: How the Technology Behind Bitcoin is Changing Money, Business, and the World, define this technology as “an incorruptible digital ledger of economic transactions that can be programmed to record not just financial transactions but virtually everything of value.”[16] Implementation of blockchain technology at any societal or organizational level will inherently make transacting (and accounting) of daily business more transparent, democratic, decentralized, efficient, and more secure.[17],[18]

The original concept of blockchain technology is based on the following underlying principles: efficiency, transparency immutability, and anonymity.[19] Sounds like a utopian combination of concepts, right? Well, the technology is here, and after making its imprint in the area of cryptocurrency creation,[18],[20] it continues to find theoretical and practical applications throughout various domains where the appearance of new and potentially disruptive forces seemed remote even a short time ago.[21],[22] In fact, the potential for disruption is substantial, affecting multiple economic sectors and industries, including banking/finance, accounting, cyber security, supply chain management, all levels of trade, consulting/forecasting, analytics/research, networking/internet-of-things, contracts/licensing, insurance, sharing of transportation/lodging, distributed cloud data storage, charitable giving, polling/voting, government systems, public benefits/welfare, law enforcement, energy management, online entertainment, retail, real estate, health-care, quality assurance, and many others.[17],[23],[24],[25],[26],[27],[28],[29],[30],[31] Finally, work is ongoing to utilize blockchain technology in implementing the concept of “universal basic income,”[17] and even creating smart devices that can “pay for themselves” using novel monetization mechanisms.[32][Table 1] provides a detailed listing of industries most likely to be directly or indirectly affected by the adoption of blockchain technology, with health-care being one of the key areas of opportunity.

Table 1: Industries and sectors with most opportunities for blockchain technology adoption. Health-care applications are shown in the first row, followed by other potential implementations

From a practical standpoint, a blockchain is an electronic ledger, where a series of transactions are grouped together into “blocks” [Figure 1].[33] These blocks are then encrypted using an algorithm called a “hash function” with the end result of the encryption accordingly called a “hash.”[34],[35] By having both the “hash” and the “hash function,” one can then decrypt (i.e. reverse encrypt) the information to access the data contained within the original block(s).[34],[35],[36] The integrity of a block (or any other dataset) is always maintained such that any changes to the original block will then result in a different “hash result.”[37],[38] A blockchain is then a series of blocks that are linked (or chained together) so that a subsequent block contains (within its dataset) the hash of the preceding block. Consequently, if the original block is changed, even though the block is encrypted, the hash will change; and therefore, it will no longer be valid or linked to the subsequent block.[24],[39]

Figure 1: Conceptual representation of the blockchain paradigm, including a permanent, immutable transaction ledger. The blockchain paradigm can be applied to any item or concept representing a defined “value or unit,” as long as it is amenable to being catalogued and permanently stored

The next component of a blockchain ledger is that the entire chain is distributed across a wide-scale peer-to-peer network.[26],[40],[41] Unlike current ledgers in which the entire dataset tends to be centralized, (e.g., a bank's network server (s), even with duplicates/backups in existence), a blockchain ledger is distributed, in theory, worldwide with ownership existing in a manner that everyone can have access to the ledger, new blocks can be added, entries can be verified, but the integrity is maintained as no singular block exists that can be modified without disrupting the entire chain. With inherent redundancy, any disruption of the chain, or the integrity of the block, can be identified by the “hash,” reconciled and repaired.[26],[33],[42],[43]

With a better understanding of blockchain technology, it becomes easier to appreciate how such a system can be used to develop a quantitative paradigm or system that is, by definition, less dependent of government institutions or the traditional banking system.[16],[44] At the same time, implications of the technology are far greater and go well beyond the “money” aspect of blockchain. In fact, in addition to the facilitation of financial transactions, blockchain-based systems can provide a structure that ensures data integrity across any objectively measurable domain, that is both transparent and potentially anonymous due to the block encryption process.[45],[46]

Blockchain Applications in Health-Care

It is well established that significant proportion of productive health-care resources simply “evaporate” because of bloated bureaucracies, inefficient (and inequitable) insurance structures, and debt-fueled, inflationary fiscal policies.[47],[48],[49],[50],[51] Thus, key objectives of blockchain-based solutions in health-care would be to reduce “red tape” and make the system “leaner,” more transparent, and more secure while re-focusing the industry's effort on its primary goal: providing value-optimized (e. g., high quality and low cost) health-care services.[52] Perhaps the most obvious applications of blockchain technologies in health-care are currently in the area of electronic medical records.[17],[53] More specifically, use cases are already being described for the introduction of blockchain-based electronic health records and medical research data collection systems.[54] Another area of application of this technology could be in creating better and more equitable distribution of resources based on “work performed” and objectively-determined productivity metrics, thus preventing misallocation of resources and malinvestment.[55] This could take a form of more sophisticated “pay-for-performance” measures, or perhaps some other form of cost- and quality-adjusted compensation schemes.[52] Finally, by transitioning health-care to a cryptocurrency model in which malinvestment and maldistribution would be much more difficult and more readily apparent, the blockchain-based paradigm could revolutionize the value equation for our patients.[18],[56],[57]

From the perspective of the patient, health-care records will be immutable and will not be able to be altered when using this technology.[58] Any attempt at access or alteration can be immediately tagged and identified throughout the blockchain. This is not only good for patient privacy but also significantly hinders criminal activities involving identity theft or falsification of records. Furthermore, authorized health-care record sharing and viewing will be much easier. When a patient visit takes place, it can be viewed by all of that patient's providers nearly immediately [Figure 2]. Using appropriate patient safety algorithms, medication errors, allergies, and medication prescriptions can be reconciled across all blockchain ledgers near-instantaneously, without the need for time-consuming medication reconciliation processes. The use of blockchain technology will thus help facilitate enhanced access to care, immediate clinical data verification, increased safety, and overall more efficient provision of care. Although theoretically anonymous, an unaltered blockchain-based medical record may still have some vulnerabilities in the context of the 1996 Health Insurance Portability and Accountability Act, mainly because of the multiplicity of nodes present across very large, decentralized blockchains.[59] However, putting into place proper “safety checks” and secondary verification technologies should not be difficult.

Figure 2: Conceptual representation of the health-care blockchain-based “health-care record ledger;” Implementation of such paradigm would help bring about the long-sought “universal medical record” where all health-care information for each individual could be permanently stored, in a secure fashion, and shared with providers and other authorized individuals, only when permitted by the record holder

In terms of enhancing patient safety, blockchain technology inherently improves the tracking (and any involved timelines) of medical errors. Having said that, given some of the built-in “error prevention” mechanisms within the blockchain structure, one could reasonably expect fewer medical errors overall, depending on how the technology is implemented. The time stamps and locations of the various patient interventions could be tracked in real-time and the sequence of events verified and saved in an unalterable format. The well-identified “Swiss cheese” etiology of medical errors could be better controlled, if not eliminated altogether. Certainly, any recorded identifiable safety occurrences (or patterns thereof) could lead to a more effective identification of opportunities for improvement, leading to further incremental enhancements in patient safety, with any resultant safety protocols contributing to better outcomes. Moreover, the use of, and adherence to, such safety protocols and procedures by specific providers could be identified, verified, and tracked.[1] As a by-product, major systemic problems such as frivolous lawsuits would become less common, while cases of verified malpractice would become readily apparent, leading to a more efficient and fairer medico-legal framework. In addition, violations of best practices and protocols could be tracked, and this could then be turned into an effective feedback mechanism, directing providers toward resources in areas where they may require continuing professional education (which itself can be recorded on the blockchain).

Physicians and other health-care providers may also realize a unique advantage through better tracking of work effort and reimbursement using blockchain-based technologies.[60] Within this paradigm, much leaner health-care systems can emerge, where the number of intermediaries would decrease significantly, and tasks that used to be delegated to third-party participants would now be seamless and automated. In a hypothetical, pay-for-performance system, providers and groups of providers could work together and compete through value-based metrics for funds that would be administered by much leaner governmental and private insurers. Within such a blockchain-based system, insurers/government will instantaneously know who did what, when, stakeholders involved, and the duration/intensity of effort.[61] The nodes of such a system, by definition, would be decentralized and could help ensure professional neutrality and balance. As a result, health-care providers would become capable of delivering better care, without unnecessary overhead and bureaucracy, and perhaps more importantly with greater professional independence.

The overall reduction in health-care fraud and unnecessary costs could translate into more affordable, higher quality care for our patients. Moreover, another largely unrealized potential benefit of blockchain-based health-care paradigm would be a continuously updating, highly reliable provider credentialing ledger.[60] An immutable record of professional training, abilities, evaluations, certification, and other pertinent information could serve as a “universal credentialing system” where physicians could interact with health-care institutions by exchanging a standardized, mutually acceptable credentialing token, reducing a plethora of unnecessary, and duplicative paperwork that often includes superfluous “cross-checks.” Such system will also be significantly more secure, protecting sensitive identity information frequently exchanged between parties in unsecured manner today.[62],[63] Before participating in such a system, all stakeholders must accept the permanence and immutability of the information stored, including adverse actions and any past or current professional sanctions.

Blockchain Applications in Academic Medicine

Blockchain technology is inherently conducive of categorizing, recording, storing, and sharing one's individual record of scholastic achievement throughout the entire career [Figure 3]. It is critical to emphasize the importance of medical research and the protection of intellectual property (IP) within the overall academic medicine paradigm.[64] With the help of blockchain-based technologies, scientific discoveries (e.g. patents, ideas, and trade secrets) can be more easily identified, located and time stamped, thereby ensuring proper attribution of IP. Blockchain technology can also play an important role in more fairly and objectively recording and valuing research, educational service, and other forms of scholarly contribution across academic health centers. In addition to helping fund science,[65] the implementation of blockchain-based paradigms can lead to better standardization of academic recognition, where the objective and unbiased “blockchain ledger” could help promote more equitable distribution of limited resources to researchers with the best, most impactful ideas.[66],[67],[68] Various conceptual frameworks may be possible here, but the most important aspect of implementation would be the differentiation of various subcomponents of one's “total academic contribution” and “tokenizing” [Figure 4] these contributions (and other relevant items across pertinent categories) into blockchain-based assets.[69],[70]

Figure 3: Idealized schematic of proposed application of blockchain-based approach to the recording and maintaining academic record of achievement; similar approach could be utilized to track productivity and performance for faculty, divisions, departments, and even entire institutions

Figure 4: The concept of “tokenization” or turning a nondigital asset into its blockchain-based representation. While traditional understanding of blockchain “tokens” has centered around their potential monetary use, the true power of blockchain technology is represented by its ability to turn any quantifiable asset into a “token” that can then be quantifiably recorded and measured.[69] Some of the items that could be “tokenized” in the current context includes a publication's impact factor, a faculty's clinical relative value unit productivity, the number of citations per publication per year, or a grant award to a principal investigator[70]

Positive consequences of blockchain-based academic credit and IP implementations would include clear attribution of IP to specific individuals, groups, and/or institutions; significantly less confusion in terms of the legal system perspective; and a more controlled and better-regulated environment for subsequent sharing and licensing of the IP.[67] Through advanced encryption, blockchain-based secure contracts would provide a backbone for immutable paper-free employment (e.g. contracts) and IP-related (e.g. licensing and royalty payment) agreements. Finally, “reduced overhead” fundraising would be possible using existing cryptocurrencies to create a framework for long-term sustainability through charitable giving across various domains of research and academia.

Potential Opportunities for International Medicine and Global Health

In the area of academic international medicine and global health, blockchain-enabled valuation system(s) could bring about equalization of effort attribution across settings (e.g. domestic versus international), instantaneous delivery of much-needed assistance to low-resource environments, and the reduction of brain-drain that plagues areas in greatest need for health-care development.[30],[71],[72] In terms of potential impact on the current global health-care system, blockchain technology may be one of the key components of securing both stability and sustainability.[73] Across the world, health-care systems are plagued by the specter of unfunded liabilities, often exceeding the gross domestic product of entire regions and/or countries.[14] When one adds to this the all-too-prevalent phenomena of fiscal misappropriation, corruption, and other systemic abuses,[74],[75] it does not come as a surprise that one's faith in “the system” quickly evaporates into thin air. Finally, let us introduce into the picture the existing differences in terms of available resources, both between and within different regions, countries, and continents.[73] Currently, no reliable mechanisms exist for equalization or redistribution of health-care resources across various settings and geographic areas. With very low transaction costs and virtually no overhead, blockchain-based solutions may be the answer to many of the problems currently hindering both humanitarian aid and charitable donations.[76] This is especially true in environments that lack established banking infrastructure.

In terms of promoting global health-care and advancing care delivery across the world, maintaining the status quo is neither sustainable nor wise. Yet solutions are few within the already antiquated system of today, with a limited repertoire of “systemic reform” tricks that usually result in “more of the same.” Blockchain-based solutions offer an elegant, egalitarian, honest, difficult-to-corrupt, universally appealing, and easy-to-use system that can be implemented across the world and help bring about equalization of resources so unevenly distributed thanks to decades and centuries of malinvestment and systemic biases. The potential for positive disruption of the global health paradigm is tremendous, beginning with a cryptocurrency-based universal global medium of health-care exchange, to monetization of health-care provider time and effort, to high-fidelity medical records powered by blockchain, to advances in medical research that are unbiased by individual convictions and beliefs, to objective research valuation based on merit/scientific impact, to hospital equipment that can “monetize itself” through the use of cryptocurrency mining algorithms, to smart contracts and universal credentialing tokens described above, and so on and so forth.[77],[78]

Miscellaneous Considerations

Our presentation may seem overly forward-looking, unabashedly optimistic, and perhaps even hopelessly futuristic. Yet, all of the advancements and implementations outlined above are possible to accomplish within the next decade using incremental enhancements based on existing blockchain technology capabilities. Among the most important considerations, the issue of data security arises whenever this general topic area is being discussed in detail that goes beyond more than superficial generalities. To that end, we must be aware that there can be both public and private blockchain nodes and/or systems, each with its own set of challenges, advantages, and unique security nuances. In terms of which type of “chain” will provide best value within the health-care system, and for which purpose (e.g. patient, provider, or institutional use) remains to be determined. It is very likely that implementations of the blockchain paradigm in health-care will move through several iterations and use cases before becoming sufficiently mature, adequately refined, and finding specific niches that are best suited for harnessing the power of this immutable ledger system.

While blockchain technology may be the next “great leap forward,” we must all be aware that all the advantages discussed and attributed to this technology may still be thwarted. While a blockchain is quite a wonderful cryptographic-based technology, it can be theoretically circumvented by a yet to be identified amount of “computing power.” Let us be forewarned that in the future, there likely will be the possibility of an organization or country acquiring such degree of aforementioned “hash power” to potentially corrupt this technology.[79]

Among other considerations specific to the health-care environment, dedicated cryptocurrency mining capabilities that are restricted (by law or convention) to qualified health-care institutions could create a powerful system for exchanging resources within and between institutions, relatively free of external influences, manipulations or other forms of interference. For example, a hypothetical “health-care coin” could be “mined” only by hospitals and other approved health-care institutions using their spare computing capacity (e.g. during off-hours), across the world, to create a platform for universal exchange of professional expertise, equipment, research, and innovation that would bring benefits to every corner of the planet. Provisions could be made within such “health-care coin” paradigm to set aside fractional quotas of “mining production,” adjustable on periodic basis, to various means (e.g. people, equipment, education, and infrastructure) at every level of the globalized health-care system (e.g. planet, continent, country, region, city, and hospital). However, for such a system to work effectively, there needs to be an efficient manner in which such “coins” can be mined. Since many cryptocurrencies are inherently limited in the number of “coins” that can exist, to prevent inflation or currency devaluation, over time, they become harder to mine. Specifically, the algorithms that are solved that produce a coin become more complicated and hence require more computational resources or processor power. This specific challenge can be circumvented in two ways: (a) by mining coins that “self-destruct” after each use, thus creating “spare capacity” for creating new coins, without undue inflationary pressures; or (b) the creation of coins that allow for a fixed and appropriately restricted inflationary growth, which could be adjusted on periodic basis but also set not to exceed certain pre-determined critical threshold(s).

In addition, there seems to be a growing number of “scams” in which computers can be sabotaged (i.e. hacked) to secretly mine for coins to the benefit of computer pirates. Such scams can result in decreased computer efficiencies – such as local processor power being usurped to mine for coins instead of performing primary computing task of supporting a health system's electronic medical record or processing radiology images – not to mention, as discussed above, increased use of electricity by the owner, which can be quite expensive if left unchecked or performed on large scale. Excess computer processing can also result in increased heat generation which then requires active cooling or may lead to premature or system failures from overuse – much like driving a car continuously at excess speeds results in inefficiency energy use and “wear-and-tear” on the engine. In addition, while by design blockchain technologies are supposed to be inherently transparent, secure, and anonymous there exists a great deal of confusion, uncertainty, and distrust – mostly due to cases of very high profile thefts of untraceable currencies. For wide-spread application in a health-care environment, especially when human lives depend on the availability and reliability of mission-critical technology, and where resources for such technology might already be inherently limited and/or constrained by societal expectations, such considerations will need to be taken into account.[80]

Solutions and Conclusions

The future is now! Let us re-design the current, badly ailing health-care system. Strategic use and thoughtful implementations of blockchain-based technologies offer to both restore sustainability to our system and extend the availability and quality of health-care services to regions of the world that need them the most. Beginning with new generation, secure medical record systems, blockchain can constructively disrupt our existing care delivery paradigms through the implementation of healthcare-specific cryptocurrencies restricted to health-care institutions and mined on spare capacity of unutilized computer equipment; built-in provisions for charity care allocations of mined “coinage;” introduction of equipment that can “pay for itself” by mining cryptocurrency while providing life-saving functionalities; facilitation of more equitable allocation of health-care compensation based on objectively-proven “work performed;” development of universal “tokenized” provider credentialing systems; introduction of merit-based rewards for high quality teaching and research; and many, many other potential downstream benefits and innovative possibilities. The choice is (collectively) ours… the only question is, “Do we want to create a better health-care system of the future?” If so, let's embark on this exciting journey and make a positive difference!

Ethical conduct of research

The current research does not require IRB/Ethics approval because it does not involve human or animal experimental designs.